Functional treatment of closed segmental fractures of the Tibia

Investigation conducted at the University of Miami and University of Southern California, USA.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca (Impact Factor: 0.39). 02/2008; 75(5):325-31.
Source: PubMed


PURPOSE OF THE STUDY Segmental tibial fractures are commonly believed to be more difficult to manage, requiring surgical treatment. Our experience with forty-eight segmental tibial fractures suggests that these fractures, if closed and with shortening of an acceptable initial degree and a corrected deformity, may be successfully treated with functional braces. MATERIAL AND METHODS Forty-eight closed segmental fractures of the tibia that had initial shortening .12 mm and angular deformity manually corrected to .7 degrees were stabilized in an above-the-knee cast for a median time of 33 days and a mode of 15 days. They were subsequently stabilized in a functional brace that allowed unencumbered motion of all joints. All other segmental fractures outside the established parameters were managed by other methods. RESULTS All fractures healed at a median time of 15.3 weeks. The final shortening was 4.7 millimeters with a mode of 12 millimeters. The maximum shortening was 14 millimeters. Fractures healed with a medial-lateral (M.L) angular deformities ranging zero to 19 degrees, a median of 5.9 degrees and a mode of 3.4 degrees. CONCLUSION The relatively early introduction of weight bearing and the freedom of motion of all joints that the brace permits seem to result in motion at the fracture site, which in turn enhances osteogenesis. As we have previously documented, the initial shortening that closed tibial fractures experience does not increase with the physiological use of the extremity. The final shortening and angulation observed in most of the fractures should not be considered complications, simply inconsequential deviations from the normal. The same should apply to closed segmental fractures.

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Available from: Augusto Sarmiento, Aug 09, 2014
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    ABSTRACT: We have carried out a retrospective review of 20 patients with segmental fractures of the tibia who had been treated by circular external fixation. We describe the heterogeneity of these fractures, their association with multiple injuries and the need for multilevel stability with the least compromise of the biology of the fracture segments. The assessment of outcome included union, complications, the measurement of the functional IOWA knee and ankle scores and the general health status (Short-form 36). The mean time to union was 21.7 weeks (12.8 to 31), with no difference being observed between proximal and distal levels of fracture. Complications were encountered in four patients. Two had nonunion at the distal level, one a wire-related infection which required further surgery and another shortening of 15 mm with 8 degrees of valgus which was clinically insignificant. The functional scores for the knee and ankle were good to excellent, but the physical component score of the short-form 36 was lower than the population norm. This may be explained by the presence of multiple injuries affecting the overall score.
    The Bone & Joint Journal 05/2010; 92(5):687-92. DOI:10.1302/0301-620X.92B5.22514 · 3.31 Impact Factor
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    ABSTRACT: We report on the use of the Ilizarov method to treat 40 consecutive fractures of the tibial shaft (35 AO 42C fractures and five AO 42B3 fractures) in adults. There were 28 men and 12 women with a mean age of 43 years (19 to 81). The series included 19 open fractures (six Gustilo grade 3A and 13 grade 3B) and 21 closed injuries. The mean time from injury to application of definitive Ilizarov frame was eight days (0 to 35) with 36 fractures successfully uniting without the need for any bone-stimulating procedure. The four remaining patients with nonunion healed with a second frame. There were no amputations and no deep infections. None required intervention for malunion. The total time to healing was calculated from date of injury to removal of the frame, with a median of 166 days (mean 187, (87 to 370)). Minor complications included snapped wires in two patients and minor pin-site infections treated with oral antibiotics in nine patients (23%). Clinical scores were available for 32 of the 40 patients at a median of 55 months (mean 62, (26 to 99)) post-injury, with 'good' Olerud and Molander ankle scores (median 80, mean 75, (10 to 100)), 'excellent' Lysholm knee scores (median 97, mean 88, (29 to 100)), a median Tegner activity score of 4 (mean 4, (0 to 9)) (comparable to 'moderately heavy labour / cycling and jogging') and Short Form-12 scores that exceeded the mean of the population as a whole (median physical component score 55 (mean 51, (20 to 64)), median mental component score 57 (mean 53, (21 to 62)). In conclusion, the Ilizarov method is a safe and reliable way of treating complex tibial shaft fractures with a high rate of primary union.
    The Bone & Joint Journal 12/2012; 94(12):1678-83. DOI:10.1302/0301-620X.94B12.29266 · 3.31 Impact Factor
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    ABSTRACT: BACKGROUND: Segmental tibial fractures are considered to be a special injury type associated with high complication rates. However, it is unclear whether healing of these fractures truly differs from that of nonsegmental fractures. QUESTIONS/PURPOSES: We therefore asked (1) does the time to union in segmental tibial fractures differ from that of nonsegmental fractures; and (2) does the complication rate of segmental fractures differ from that of nonsegmental fractures? METHODS: We retrospectively studied 30 patients with segmental tibial fractures treated at a Level I trauma center from January 2000 to December 2008 and compared healing and complications with a matched control group of 30 nonsegmental tibial fractures. In followup we determined time to union, delayed and nonunion, and overall complication rates. Patients were followed at least until union was attained. The minimum followup was 5 months (median, 15 months; range, 5-54 months). RESULTS: Median time to union was 34 weeks (range, 12-122 weeks). Segmental fractures took longer to heal than nonsegmental fractures (median, 34 weeks; range, 12-122 weeks and median, 24 weeks; range, 11-39 weeks, respectively). The overall rate of complications was higher in segmental fractures as was the necessity for reoperation to attain healing. CONCLUSIONS: Healing of segmental tibial fractures is characterized by substantially more complications and longer healing times than nonsegmental fractures and should be considered as a special type of injury. We believe these should be treated in specialized trauma centers. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 12/2012; 471(9). DOI:10.1007/s11999-012-2739-z · 2.77 Impact Factor
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